Home Care, Overtime, & Unintended Consequences

Consumer Directed Personal Assistance Association of New York State - October 24, 2014

This is one hell of a mess of an issue, and the headline on that Businessweek article is horribly misleading. Here’s how it breaks down:

- Most disabled people who use home care don’t pay for it out of pocket. It’s usually paid for by Medicaid. Medicaid sets the pay rates, so if you are disabled and get home care through Medicaid, you have no control over how much your aides are paid. You can’t give them a raise, and you can’t, on your own, start adding overtime to their paychecks. In fact, under Medicaid, you don’t write the paychecks at all.

- Aides should be paid for overtime. Or, rather, they should be paid more overall, and have better benefits. Most disabled people agree, and would love to be able to pay their home care aides better. But again, most disabled people have no control over what their aides are paid.

- Medicaid is a joint federal / state program, but rates and budgets for home care are set by states. So, while the federal government certainly has the authority to insist on aides being paid for overtime, it can’t force states to increase their home care budgets to pay for the increased costs. If they do, then fine. But states that don’t respond to the mandate will have to cut or cap hours of service. As both of these articles point out, the 50 states have different budgeting schedules, so even under the best case scenario, at least some states won’t increase their budgets until well after the overtime mandate goes into effect.

- A few of hours a week less service can truly make the difference between independence and being forced into a nursing home. Home care programs already pare services down to the absolute minimum for each individual person served. Most disabled people can’t just “make do” with less aide time. It’s not a psychological thing. Home care aides aren’t like security blankets, there to make disabled people feel safe. Arbitrary reductions in services upset the whole foundation of disabled peoples' independence.

- Home care aides are not butlers, maids, or cooks. They aren’t quite the same as nurses in a hospital, either. Home care work lies somewhere in between. But the key thing to keep in mind is that for the people who need it, home care isn’t optional. It isn’t a luxury. It makes independent life in the community possible, not just easier.

- There are probably ways to make this work for disabled people while also increasing pay to home care workers, but getting it all done, in every state, before the overtime mandate is due to kick in is a long shot.

Apart from the actual damage this whole thing might do if it isn’t handled correctly, it is a prime example of what can happen when well-meaning policy wonks … with a lot of good instincts … don’t know squat about how disability-related programs actually work.

Sadly, this mainly technical problem threatens to pit disabled people against workers, and vice-versa, when in fact both constituencies have so much in common.